Ophthalmic & Physiological Optics ISSN 0275-5408
LETTER TO THE EDITOR
Statutory requirements for visual fields and IOP measurement during an NHS Eye Examination in Scotland Dear Editor-in-Chief, The editorial by Professor Lawrenson that was part of the virtual OPO Glaucoma1 issue stated that there was no statutory requirement for optometrists to perform central visual fields or intraocular pressure (IOP) measurement during an NHS eye examination. However this is not the case in Scotland.2 Automated supra-threshold visual fields are mandatory during a primary NHS eye examination if the person has a family history of glaucoma (aged 40 years and over), raised IOP, suspect glaucoma or anyone who presents for their eye examination for the first time at a practice after their 60th birthday. In addition any primary exam for a patient aged 40 years and over or with suspect glaucoma must include IOP measurement. Whether increased regulation of NHS eye examinations enhances patient care is an interesting question. A study by Ang et al.,3 conducted in 2006 did provide some evidence that glaucoma was detected more accurately following the changes in legislation in Scotland.
However this improvement may also have been influenced by the introduction of funding in 2006 to perform threshold visual fields and applanation tonometry as a supplementary NHS test in Scotland. Ross Henderson WJ Henderson Optometrist, Perth, Scotland E-mail address: [email protected] References 1. Lawrenson J. Glaucoma: the challenge of early case detection. Ophthalmic Physiol Opt 2013; 33: 3–6. 2. The National Health Service (General Ophthalmic Services) (Scotland) Amendment Regulations 2010. 3. Ang GS, Ng WS & Azuara-Blanco A. The influence of the new general ophthalmic services (GOS) contract in optometrist referrals for glaucoma in Scotland. Eye 2009; 23: 351–355.
Author’s response Dear Editor, I am very grateful to Dr Henderson for pointing out the differences in the General Ophthalmic Services (GOS) regulations between Scotland and the rest of the UK. Whilst the optometrist has a duty to their patients to carry out whatever tests are necessary with respect to the detection of signs of disease, the actual tests performed are at the discretion of the individual optometrist. However as a minimum, optometrists must comply with legal requirements, as determined by statutory GOS regulations. In England, the required content of a ‘sight test’ (whether performed under the GOS or privately) is laid down in the ‘Sight Testing (Examination and Prescription) (No. 2) Regulations 1989 which states1: When a doctor or optician tests the sight of another person, it shall be his duty to perform, for the purpose of detecting signs of injury, disease or abnormality in the eye or elsewhere: 1. An examination of the external surface of the eye and its immediate vicinity, 2. An intra-ocular examination, either by means of an ophthalmoscope or by such other means as the doctor or optician considers appropriate, 102
3. Such additional examinations as appear to the doctor or optician to be clinically necessary. Similar regulations for the GOS are in place for Wales and Northern Ireland. The College of Optometrists Code of Ethics and Guidance for Professional Conduct provides advice regarding which additional procedures or tests should be performed in particular clinical circumstances. With regard to examining patients at risk from glaucoma, the College guidance states that good practice should include an assessment of the optic nerve head and tonometry and may also include ‘central visual field assessment using perimetry with threshold control’. In 2006, the terms of the GOS contract in Scotland were changed significantly. The National Health Service (General Ophthalmic Services) (Scotland) Regulations 2006 currently provides the definition of a primary eye examination in Scotland and specifies the tests and procedures which need to be performed in particular circumstances.2 Suprathreshold visual field testing is specified in the following patients: 1. Adults aged 40 and over who have a family history of glaucoma 2. Patients with suspect glaucoma or ocular hypertension
© 2013 The Authors Ophthalmic & Physiological Optics © 2013 The College of Optometrists Ophthalmic & Physiological Optics 34 (2014) 102–103
Letter to the Editor
With respect to patients over 60, the recommendation is that supra-threshold fields are performed ‘on a screening basis’. Although the GOS regulations in England and Wales are similar, as part of the Wales Eye Care Service (WECS),3 accredited optometrists are able to perform an extended ‘Eye Health Examination’ for those patients ‘at-risk of sightthreatening eye disease’ following the completion of a standard GOS sight test. The following procedures are considered to be mandatory for the Welsh Eye Health Examination: 1. Visual acuity measurement 2. A slit lamp examination of the anterior segment 3. An assessment of the anterior chamber angle 4. Contact tonometry using a Goldmann or Perkins tonometer 5. A dilated fundus examination using a slit lamp and a Volk lens 6. A visual field examination, from which a quantifiable field printout is available 7. Other procedures at the discretion of the examining optometrist or OMP Given that the vast majority of referrals for open angle glaucoma are generated by community optometrists through
opportunistic case-finding, the variability in the mandatory content of the primary care eye examination across the UK, particularly for those at greatest risk of developing the disease, may compromise glaucoma case-detection. John G. Lawrenson City University, London, UK E-mail address: [email protected] References 1. Sight Testing (Examination and Prescription) (No. 2) Regulations, 1989, http://www.legislation.gov.uk/uksi/1989/1230/ made, accessed 14/11/13. 2. The National Health Service (General Ophthalmic Services) (Scotland) Regulations, 2006, http://www.legislation.gov.uk/ ssi/2006/135/contents/made, accessed 14/11/13. 3. A service and clinical guide for the Eye Health Examination Wales (EHEW) part of the Wales Eye Care Service (WECS). For optometrists and ophthalmic medical practitioners (OMPs), http://www.eyecare.wales.nhs.uk/ehew, accessed 14/11/13.
© 2013 The Authors Ophthalmic & Physiological Optics © 2013 The College of Optometrists Ophthalmic & Physiological Optics 34 (2014) 102–103
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LETTER TO THE EDITOR
Statutory requirements for visual fields and IOP measurement during an NHS Eye Examination in Scotland Dear Editor-in-Chief, The editorial by Professor Lawrenson that was part of the virtual OPO Glaucoma1 issue stated that there was no statutory requirement for optometrists to perform central visual fields or intraocular pressure (IOP) measurement during an NHS eye examination. However this is not the case in Scotland.2 Automated supra-threshold visual fields are mandatory during a primary NHS eye examination if the person has a family history of glaucoma (aged 40 years and over), raised IOP, suspect glaucoma or anyone who presents for their eye examination for the first time at a practice after their 60th birthday. In addition any primary exam for a patient aged 40 years and over or with suspect glaucoma must include IOP measurement. Whether increased regulation of NHS eye examinations enhances patient care is an interesting question. A study by Ang et al.,3 conducted in 2006 did provide some evidence that glaucoma was detected more accurately following the changes in legislation in Scotland.
However this improvement may also have been influenced by the introduction of funding in 2006 to perform threshold visual fields and applanation tonometry as a supplementary NHS test in Scotland. Ross Henderson WJ Henderson Optometrist, Perth, Scotland E-mail address: [email protected] References 1. Lawrenson J. Glaucoma: the challenge of early case detection. Ophthalmic Physiol Opt 2013; 33: 3–6. 2. The National Health Service (General Ophthalmic Services) (Scotland) Amendment Regulations 2010. 3. Ang GS, Ng WS & Azuara-Blanco A. The influence of the new general ophthalmic services (GOS) contract in optometrist referrals for glaucoma in Scotland. Eye 2009; 23: 351–355.
Author’s response Dear Editor, I am very grateful to Dr Henderson for pointing out the differences in the General Ophthalmic Services (GOS) regulations between Scotland and the rest of the UK. Whilst the optometrist has a duty to their patients to carry out whatever tests are necessary with respect to the detection of signs of disease, the actual tests performed are at the discretion of the individual optometrist. However as a minimum, optometrists must comply with legal requirements, as determined by statutory GOS regulations. In England, the required content of a ‘sight test’ (whether performed under the GOS or privately) is laid down in the ‘Sight Testing (Examination and Prescription) (No. 2) Regulations 1989 which states1: When a doctor or optician tests the sight of another person, it shall be his duty to perform, for the purpose of detecting signs of injury, disease or abnormality in the eye or elsewhere: 1. An examination of the external surface of the eye and its immediate vicinity, 2. An intra-ocular examination, either by means of an ophthalmoscope or by such other means as the doctor or optician considers appropriate, 102
3. Such additional examinations as appear to the doctor or optician to be clinically necessary. Similar regulations for the GOS are in place for Wales and Northern Ireland. The College of Optometrists Code of Ethics and Guidance for Professional Conduct provides advice regarding which additional procedures or tests should be performed in particular clinical circumstances. With regard to examining patients at risk from glaucoma, the College guidance states that good practice should include an assessment of the optic nerve head and tonometry and may also include ‘central visual field assessment using perimetry with threshold control’. In 2006, the terms of the GOS contract in Scotland were changed significantly. The National Health Service (General Ophthalmic Services) (Scotland) Regulations 2006 currently provides the definition of a primary eye examination in Scotland and specifies the tests and procedures which need to be performed in particular circumstances.2 Suprathreshold visual field testing is specified in the following patients: 1. Adults aged 40 and over who have a family history of glaucoma 2. Patients with suspect glaucoma or ocular hypertension
© 2013 The Authors Ophthalmic & Physiological Optics © 2013 The College of Optometrists Ophthalmic & Physiological Optics 34 (2014) 102–103
Letter to the Editor
With respect to patients over 60, the recommendation is that supra-threshold fields are performed ‘on a screening basis’. Although the GOS regulations in England and Wales are similar, as part of the Wales Eye Care Service (WECS),3 accredited optometrists are able to perform an extended ‘Eye Health Examination’ for those patients ‘at-risk of sightthreatening eye disease’ following the completion of a standard GOS sight test. The following procedures are considered to be mandatory for the Welsh Eye Health Examination: 1. Visual acuity measurement 2. A slit lamp examination of the anterior segment 3. An assessment of the anterior chamber angle 4. Contact tonometry using a Goldmann or Perkins tonometer 5. A dilated fundus examination using a slit lamp and a Volk lens 6. A visual field examination, from which a quantifiable field printout is available 7. Other procedures at the discretion of the examining optometrist or OMP Given that the vast majority of referrals for open angle glaucoma are generated by community optometrists through
opportunistic case-finding, the variability in the mandatory content of the primary care eye examination across the UK, particularly for those at greatest risk of developing the disease, may compromise glaucoma case-detection. John G. Lawrenson City University, London, UK E-mail address: [email protected] References 1. Sight Testing (Examination and Prescription) (No. 2) Regulations, 1989, http://www.legislation.gov.uk/uksi/1989/1230/ made, accessed 14/11/13. 2. The National Health Service (General Ophthalmic Services) (Scotland) Regulations, 2006, http://www.legislation.gov.uk/ ssi/2006/135/contents/made, accessed 14/11/13. 3. A service and clinical guide for the Eye Health Examination Wales (EHEW) part of the Wales Eye Care Service (WECS). For optometrists and ophthalmic medical practitioners (OMPs), http://www.eyecare.wales.nhs.uk/ehew, accessed 14/11/13.
© 2013 The Authors Ophthalmic & Physiological Optics © 2013 The College of Optometrists Ophthalmic & Physiological Optics 34 (2014) 102–103
103
